Transcript

(To translate please select your language to the right of this page)

DR GOLNIK: Greetings. This is Dr. Karl Golnik, the Director of Education for the International Council of Ophthalmology. Welcome to this special Orbis webinar, designed for people, hopefully, who are either currently using a wet lab or want to start using a wet lab. As per all Orbis webinars, there will be an opportunity for you to type in any questions in the chat box, per usual. And I think this webinar we may actually be having some verbal possibilities as well. We’ll see how that runs. But certainly during the course of the webinar, please feel free to type in any questions in the chat box, and then we’ll see if there’s audio available. Today’s topic is on, of course, creating a wet lab. And I’m just gonna show one slide before I introduce our special guest speakers, as to — why do we need a wet lab? And we’ve talked about this in the past, if you were at the meeting in Tanzania. But it allows a number of things. And Michael, I think, will talk about this in more detail. But in particular, it allows the students to practice at their own pace and abilities, without the danger and stress and so on of being with a live patient. Hopefully it allows the development of skills and trust and coordination. And of course, ideally, the student arrives better prepared for their first patient. We want the students to be up here somewhere on the learning curve, as opposed to down here, when they start with live patients. So I’m gonna go ahead and introduce both the speakers right now. The first speaker will be Dr. Michael Griess, who is the anterior segment wet lab director at the University of Iowa. He completed his medical and residency training at the University of Nebraska, and works extensively, currently, with residents and students in the wet lab. In fact, a whole day per week is my understanding. So he will talk first. And any questions you have for him — please type in the chat box as he is talking, as he will have to leave the webinar before it is over. Our second speaker will be Dr. John Clements, who has a special interest in international ophthalmology, and indeed spent three years as medical director of the Boa Vista Eye Hospital in Angola. So he has very practical experience, and during that time did over 9,000 surgeries in complex cornea, cataracts, and ocular surface tumors. He’s now at the Casey Eye Institute at the Oregon Health and Sciences University, where he practices cornea and refractive surgery. So he’s also very interested in pursuing international ophthalmology interests. So without further ado, I will turn it over to Dr. Michael Griess.DR GRIESS: Hello! All right. So I’m gonna talk a little bit about why wet labs are important. Everybody see my slides, I hope? So wet labs are extremely important, because we are putting our hands on patients, and surgery is not a natural ability. So we’re gonna talk about why wet labs are important. The learning problem. And what we did at the University of Iowa, approximately 10 years ago, where we dramatically changed our wet lab curriculum, and talk about why we did that, and how we went about doing that. So the problem that we have is that, again, surgery has real complications, and real effect on our patients’ lives. When we studied our surgical complications, essentially, for phacoemulsification, cataract surgery, at the University of Iowa, from 1997 to 2003, we found that there was a significant learning curve. Residents who had not done many cases had significantly higher complication rates than surgeons who had done more cases. So we wanted to try to identify a way to reduce those early complication rates. Another study done around the same time at Emory University showed a significant effect as well. So we know that early surgeons have higher complications, and we wanted to try to figure out why, and how we could reduce those complications for our patients. So at Iowa — this predates me, but we decided to change the curriculum. The curriculum previously had been more of — as you do on your own time, give some small assignments, and the residents would frequently do it after hours. But that just wasn’t working. So at Iowa, we decided to make it a structured wet lab, with dedicated time during the week. During normal business hours. To give the residents time to do that. So we also adapted how we treated patients in the OR, where we did deliberate practice, and the residents would do parts of cases. So one way we do that here at Iowa is — early on in training, the residents will spend a surgical day with Tim Johnson, one of our busy cataract surgeons, and they are assigned to do capsulorrhexis that day. So they are focused on that one aspect of surgery, and they practice that and do deliberate practice, and that is basically all they get to do that day, is capsulorrhexis. And that works really well, getting residents focused on a task, and practicing that one task. Then at the end of the day you go through all the capsulorrhexi and give formative feedback directly to guide them. So we changed our surgical curriculum to accommodate those parts, and follow-up studies showed that we were able to reduce our complication rates in the early cases for our residents, as well as also the later cases. So it transmits throughout their surgical training. The better we can do early, before they get into the operating room, that will continue that throughout their career, to help them. And help our patients. So setting up a structured wet lab — again, I think the most important part about a wet lab is the structure. You have to have a curriculum in place. Just doing it after hours, having the residents go on their own, does not seem to work as well. So you want to have specific goals and objectives, and I’ll show you where you can find our Iowa curriculum. We do pre- and post-testing. They have reading assignments before each lab session. We talk about them throughout the lab. We do a quick little test afterwards. And then we’re very blessed here at Iowa to have funding that allows me to spend time with our residents. But I am there with them, while they’re doing the wet lab, and we’re doing practical testing. I’m challenging them. So that’s extremely helpful. The actual setting up a wet lab can be one of the bigger challenges, I would suspect, in your region of the world. The funding to have the supplies. Microscopes. We have a lot of interesting simulators available to us. We have lots of artificial eyes. But there are real costs involved with those, obviously. And again, we’re very blessed here to have faculty sessions every week. And every facility is not going to have the ability for their residents to spend 6 to 8 hours with a faculty member every day, but our residents really think that’s a positive part of our program, that we get that direct hands-on. So this is a great article, published in the Journal of Cataract and Refractive Surgery in 2009. Which talks about the basic approaches to setting up the lab. Again, the key portions are to set up a physical space. You need to have the space to do it. In some programs here, even in the US, the residents even use their normal operating room space. They do it after hours. It is ideal to have a separate space, so that you’re not getting in the way of clinical activities. But with limited resources, it’s perfectly appropriate to use your normal clinical space, if you’re careful. Clean the instruments. And all those things. Again, establishing appropriate faculty and curriculum — I’ll talk about our phaco curriculum here, because that’s what I have experience with. I think John Clements will talk about small incision cataract surgery, his experience with that. So obtaining practice eyes, stabilizing the eye, preparing the eyes — different regions of the world will have different animals available to them. But there are multiple good animal models that are very helpful for practicing phaco surgeries. Suturing. Practicing anterior segment surgery. We’ve tended to steer away a little bit from animal tissue now, because we have the funding to purchase the artificial eyes. But otherwise, we have a lot of cattle and pigs in this region of the world, in Iowa, so we do utilize tissue from those animals, for practice. Again, funding can be the biggest challenge. We’re very blessed here to have supportive alumni, so we have great funding, so I would recommend that all sites be diligent about saving suture, saving any things that you can reuse. So even though we have great funding, I still save viscoelastic, if it’s not completely used at the end of the case. We save halves of suture, if it wasn’t used. So we still are very aggressive in saving items. We purchased a new phaco machine, and thankfully, our hospital donated a phaco machine to us. So we still have to scrap for funding, to fund our lab. The Iowa wet lab curriculum is available online, readily available. I actually never bookmark it. I just type Iowa wet lab, and it usually pops up, if I search on Google or various search engines. And so you can see the dedicated curriculum that we’ve developed here at the University of Iowa. Which is very phacoemulsification-heavy, because that’s the majority of our cases. But you can see how the curriculum is structured. Again, we have reading assignments ahead of time. And a lot of the curriculum is not real surgery. We use our Eyesi simulator. We use various things. Just getting residents and students used to working under a microscope is one of the biggest challenges that you have. It’s not a natural skill to get under the microscope and use both hands and both feet on the microscope pedal. So just getting the residents underneath the scope and using things can be incredibly helpful. So this is a sample page from one of our curricula — we have a set of objectives ahead of time. We say we’re going to do these things. We’re going to fold this many lenses. And that way we structure it and we get it accomplished. It’s always difficult. There’s phones. So interrupting — so and so patient needs something — so it’s great to have structure, so that every resident has to go through that curriculum. So, again, it’s extremely important to put it down. So this is another sample portion of one of the curricula, where we have video links for them to review ahead of the lab assigned for the day, reading assignments that we use. Again, all of these are readily available for everyone on the internet, so that you can view our curriculum. So, again, just type Iowa ophthalmology wet lab or Iowa wet lab, and it will typically pop up for you. And just real brief — I know this is outside the funding level for many programs, but the new artificial technology has really changed how we do our lab here. And it’s extremely helpful. But unfortunately, there are recurring costs. So we use a combination of models right now. The Kitaro system — so the Bioniko system, which is a system from the US that has multiple modules. This module — we’re able to teach iris suturing. So there’s some really interesting stuff. And some of these model systems can be used over and over. This iris suture model from Bioniko can be used multiple times. So it’s really great stuff that’s available to us now. So based in England — there’s another group… Again, the biggest downside to this technology is the cost involved. But certainly at any international meetings, I would certainly seek out these vendors and chat with them. I know the American Academy of Ophthalmology is working with a couple of these vendors on trying to help bring down costs. For programs to be able to use these items in their wet labs. So… Another model that allows practice, using iris expansion techniques, either iris hooks or the Malyugin ring. Again, this model can be used over and over and over again, to get residents to practice on using these devices. So, again, there’s lots of great stuff out there that can really make a difference. I know the Malyugin came out after I trained, and I was hesitant to use it more, until I was able to practice it multiple times like this in the lab. And I’m a better surgeon myself, just by teaching my residents how to use these items in the lab. So, again, to conclude, early risk is the problem. So structured training is what really works. The best simulation tool depends on what you’re trying to teach. We use the virtual reality simulator a lot to practice bimanual training, working under a microscope, working with foot pedals. Wet lab suturing is a great thing to do. So just suturing — just helps spend time under the scope. Again, the artificial eyes, we’ve found, have been more helpful for teaching phaco. But animal eyes still have a role in teaching residents. A quick slide that has the various links for some of those products that you can purchase. I have no financial interest in any of these products, of course. All right. Thank you. I’ll turn it over to John.

>> There are no questions at this time.

DR CLEMENT: No problem. My fault. So for my context, I was trained in the United States, and I did a fellowship in Boston, in cornea and refractive surgery. And I promptly went on to Angola, to run a mission hospital there. And for about the first 6 months, I was really enjoying things, doing just an incredible volume of manual small incision cataract surgery there. But I talked to my directors of the hospital, to say — hey, you know, this is fun for me, to do these surgeries myself, but I really want to be training doctors in how to do cataract surgery in our context. And so we agreed to stay there for several years, in order to run a surgical training program. And in the process of training doctors, had to figure out how to make a wet lab happen in a relatively low resource context that I faced in Angola. And so what I’ll talk about here will largely be my experiences in the resource setting of Angola. And this photo here demonstrates kind of the goal of the surgical wet lab, to see… This is Dr. Lupsi, one of our surgical trainees, doing cataract surgery independently. And the goal is that our trainees are able to do the surgeries independently, safely. These photos here show pictures of surgeries that were unfortunately not done very well. The upper photo is showing an iris prolapse, the day after surgery. You can see the peaked pupil here. And that knuckle of iris sticking out. This is certainly a complication that can be avoided by proper wound construction during our surgical procedures. This complication is really difficult to fix, postoperatively, to get the iris back into the eye. It’s dangerous for our patients. We want to avoid that. And then I think most experienced surgeons will recognize this picture on the bottom right as bullous keratopathy, second to endothelial damage from surgery that has not gone very well. So we really want to use the wet lab to help reduce these potential damaging complications to our patients. As Michael mentioned, a wet lab should not be done haphazardly. It ought to be done — written into the curriculum, so that there’s an understanding that if a surgical trainee is involved in the program, the wet lab is not optional. I made that mistake of inviting informally some of our trainees to participate in the wet lab, and was disappointed by the lack of attendance. So I learned early — there are other factors at play that might sometimes make trainees unable to attend optional training sessions. So be sure to make this into a written curriculum, that it’s an understanding that trainees will be there, and to actually schedule a time well in advance. In our context, I ran a busy surgery center, doing surgeries five days a week. And so finding the time to do the wet lab, away from busy clinical — actually doing surgeries — was a bit of a challenge. But you have to see the long view, take the long view of things. Sometimes even if you slow down your surgical productivity, with the idea of doing good surgical training, it will pay dividends later on, as those trainees become proficient at surgery. So do think about how you schedule the wet lab. The very first steps in doing wet lab do not involve globes or simulators or any of those things, in my opinion. The very first thing is a very cheap package of 10-0 nylon suture. And so this is a picture of what my first surgical simulators would look like for my trainees in Angola. The 10-0 nylon packages have very nice foam inserts that you can cut the suture in half, use a blade of some type, and create an incision. It may be a little hard to see on the screen, but you can make a cut in the center of that packaging, and then have the trainee place nylon sutures in that little foam packaging. It really does a nice job of teaching dexterity under a microscope. Many of the beginning surgeons do not have an understanding of spatial recognition, underneath the microscope. So using this technique is very cost effective. We would use leftover sutures or expired sutures to do this. And the goal for them is to place perfect sutures. And you see these sutures here are all mostly well centered over the incision. Mostly the same size and length. All the knots look fairly symmetrical. And so I would want them to create at least 50 good sutures, before we would even think about moving on to a globe. Because globe wet lab simulations requires some amount of setup and expense. And getting into doing that situation with a trainee who doesn’t really know how to focus the microscope or use focusing pedals, has a difficult time with their hands underneath the microscope — it’s very frustrating. So, for me, this was a kind of very low cost investment tool to really just train them, how to use their hands underneath a microscope. It’s really important that the teacher be present for the first several attempts at tying corneal sutures under the microscope. You know, they will need lots of assistance. So how do you tie that knot? What technique to use? I recommend starting off with a 3-1-1 suturing technique. And you can become more advanced after that. But being present to see them do the first several knots is a really good idea. After they’ve done a couple, it’s fine to leave them by themselves, with the goal of saying — hey, give me 10 or 20 really good knots. And then you can come back and look at their work and you can inspect it later to see how they’ve done. Once we’ve done suturing practice, it’s time to do globes. And so we don’t have — we didn’t have access to Eyesi simulators or Kitaro or the Phillips model, these nice, really fancy simulators. And so I was trying to figure out how to get globes to use in practice. And so I said… Well, you know, there’s no distributor. Here in the US, if I really want animal eyes, I can look online and say — hey, I would like 50 pig eyes. Send them to this address. We would have them sent. Didn’t exist for me in Angola. So the local market served quite nicely for this. To go and obtain 4 or 5 pig heads. That was my preference. The pig eye works the best, among the large mammals. Goat is a second. Cow is a third. Just — the cow eye is so large that it’s not quite as effective. A pig eye is larger than a human eye, but it more closely approximates the human anatomy. So that would always be my preference. And the experience of doing enucleations is a plus for this. So having an orbital anatomy day, removing pig eyes. This can be a really — somewhat of a morale builder for the staff, too. I would have nurses help participate with us. In the picture here, you can see Pedro, in the plaid shirt. He’s one of our nurses. And then Dr. Mabatiti is the one actually working on the eye. And so I would give out — I think we would buy these pig heads for about $10 a head. And then actually my nurses really enjoyed putting these on the barbecue afterwards. So we would take the eyes, and then they would have a barbecue afterwards, and they would eat the remainder of the head. So it was a really fun time for the staff. They ended up really enjoying wet lab preparation day. You know, I would suggest doing multiple globes. It’s not that efficient to just do one head at a time. I would have them recover 6 to 8 eyes at a session. And they can be frozen for later use. Put in the deep freeze. The tissue quality does degrade if you keep these in the freezer for a long period of time. But they’re still useful for practicing. Definitely the best quality is to use the eyes on the same day that they are obtained. The tissue quality is certainly best. But can be used later on as well. In order to do a wet lab for the manual small incision cataract surgery, you really need the same materials that you would use for actual surgery. But we did have a dedicated set of instruments that we kept, just for our wet lab. I won’t read off all of the instrument names here. But these are the instruments that are required. And for us, we would obtain the instruments from a supplier in India. So we could buy all of the instruments that we needed for the wet lab, for under $100, for the kit. So with just a little bit of funding, you can have several instrument sets that you could dedicate to the wet lab. I have also used surgical instruments that would later be used on human eyes, a practice that would be frowned on in the United States, but with good sterilization practices, I never had any infections or problems. So this was an actual picture of our wet lab. And so one of the things that, with the animal globe, to use — in terms of securing the eye, they do make very nice foam models. Which, frankly, are likely not that expensive. I didn’t have those at the time of this photo. So we just created, using simple foam packaging — we cut out a hole, placed, essentially — placed the globe and pinned it down. So that’s what you’re seeing here, is working on very simple foam inserts there, that we cut a hole into, that the globe could then be secured. Not very fancy. The microscope that you see here was actually one of our — for our center, we had several dedicated microscopes for our operating block. This microscope, when we went out on our traveling sort of cataract camps — so we used this for the wet lab setting. It’s a Scan Optic microscope. Relatively cheap. It comes out of Australia. I think this microscope sells for less than $4,000. Not the best optics of any microscope that I’ve used, but certainly good enough for the wet lab setting. And we did use… We did not use our main operating room for our wet lab. This is a secondary minor procedure area. And so I think if your center does have access to a minor procedure area, or other less sterile place, we tended not to want to bring in the animal eyes and other instrumentation into our operating room. But you could certainly do that with really fastidious sterilization practices. I think any infections could be avoided. Some surgical steps in the wet lab that you might not have to think about with human eyes — oftentimes, the dead animal eye globe can be very soft. And a hypotonous eye is difficult to manipulate. Particularly things like scleral tunnel creation for manual small incision cataract surgery — a soft eye is difficult. So you can simply use a small 27-gauge needle, with some saline on a syringe, and inject the vitreous, to make the eye more firm. That has to be measured. If you increase the pressure too much, any manipulations inside of the anterior chamber will be pointless, because a large amount of posterior pressure will cause prolapse of the anterior chamber contents. So judicious inflation of the eye may be necessary. You know, the first thing to do, starting off with globe eyes, is to start with incision creation. Make a very good depth scleral scratch and proper scleral tunnel. It can very easily be done with these eyes, with attention being paid to the depth of the incision creation, making sure they’re not making the tunnel either too superficial and buttonholing, or too deep, with a premature entry. Capsulotomies — very nice model to use for capsulotomies, using Trypan blue. The red reflex will be quite poor, so getting your trainee into the anterior chamber, and using Trypan blue to stain the capsule. Whether you’re teaching a capsulorrhexis technique or a can opener, the Trypan blue is really nice for the learner to understand the effect that the cystotome needle has on the anterior capsule. One of the really most important parts, when you’re doing manipulations in the anterior chamber, in terms of how to teach your trainee, is how to maintain the proper depth of the anterior chamber. In doing so, maintaining a good depth of the anterior chamber, and avoiding contact with the endothelium, you hope to prevent pictures like we saw earlier, with a very cloudy cornea that suffered endothelial damage. So that if the anterior chamber is flattening all of the time, when the student is inside the anterior chamber, it’s a good point to intervene, to show them how they could maintain the chamber better, by not pushing posteriorly on the wounds of the eye. The globe practice for suturing is really, really important. You know, you really don’t want the first time a trainee is attempting to close a surgical wound to be on a live human being. Because you would be surprised at the number of errors that will be made in actual surgeries. So having suture practice to close wound and create watertight closure on the animal eye is really vital to good success. One point that I should mention: Oftentimes, complete surgical completion of a cataract surgery on a dead animal eye is — oftentimes more difficult than a live human eye. The tissue may not be quite as nice. And particularly if you’ve frozen the eye in the freezer for a period of time, the tissue may be kind of soft and boggy. The zonules at times — depending on the method that the market or the butcher used to kill the animal — I’ve had several eyes where the lenses were nearly dislocated into the vitreous, because I found out later they would smack the animal on the head to knock them unconscious for the butchering process. So they gave them lens dislocations. So the focus really should be on proper theory and practice with manual dexterity. Certainly if the learner is able to complete a manual cataract surgery on the animal eye, they will definitely be ready for live exercises. Feedback is a really important part of surgical instruction. And feedback in the wet lab setting — it’s no different. The only difference is in the live surgery, when you’re doing feedback with your trainee, it often involves stepping in and saying… Hey, you know, Dr. Smith, that surgery is not going so well. Allow me to step in and correct this. In the wet lab, I really attempt to make that feedback much more verbal feedback, and less hands on. This is the time for mistakes, in the wet lab context. But it really is — it’s very important for the live instructor to be present for the sessions. For the reason of guiding the trainee. So it really is not productive to hand a trainee a globe and say — hey, go practice cataract surgery yourself. It really is very important for the instructor to be there. At least for the first several sessions. Once again, later the trainee can go at it alone, once they’ve gained some skills. The post-wet lab — I really like to have debriefing sessions with the trainees. And it starts off really for me — rather than initially bombarding them with my criticisms, asking them how do they think that went. And so getting their opinions, saying — Doctor, how do you feel that went? Were you confident? Were there areas you felt you could improve upon? And hearing their feedback gave me a really good understanding of where they were at with their own perception, versus reality. And certainly had instances where doctors told me that they felt great. That things were ready. That they were ready to go into surgery on real live eyeballs. And I thought that… No! That was not very good. You know? They couldn’t make a good wound. The wound was very short. Or they’re buttonholing. And I would tell them… Well, I’m glad you’re feeling more confident. But actually, we need to work a few more times to make these wounds better, before entering into surgery. And sometimes that led to some kind of difficult discussions, as they disagreed with my assessment. But it really did help me in understanding kind of their thought process, where they were. Also important to give written feedback afterwards. And this is a tool that I did not use during the time. But after I left Angola, a friend of mine showed me this, from the International Council of Ophthalmology. Their OSCAR, the Surgical Competency Assessment Rubric. Specifically designed for SICS. A friend of mine, Will Dean, shared this with me. And it goes really well, sort of in a step by step assessment of surgical skills. And so it’ll break down — you know, once again, this is a specific tool for manual small incision cataract surgery. But it breaks it down to things like scleral fixation. In terms of creating the wound. How well does the trainee hold onto the globe? Is there a good position of fixation? No need for multiple regripping. Mild tissue trauma. Or, you know, when they’re grabbing onto the sclera, maybe they’re not able to do it. Maybe they can’t hold onto the sclera. They’re not doing it in the appropriate place. Or maybe they really tear up the eye when they’re holding onto it. And you can grade them between 0 and 2. And this will go through, with all steps of the manual small incision cataract surgery. And this can be implemented in the wet lab setting, with animal eyes, to show how well the trainee is progressing. And it can be a useful tool to follow along a learner’s progress, in terms of how well they’re doing in a wet lab setting. And it can be a tool to use like — is this learner ready to start doing surgery on live human beings? You know, if all of their scores are over here in the novice category, and creating lots of problems in the wet lab, it’s probably not wise to allow them to start touching your surgical patients. You very well might find many complications, postoperatively. But if your trainees are getting into the advanced beginner and competency phase, then it’s certainly time to get them started on live surgical activities. Some of the things here that, in the global indices on this, the final portion here, I think a really good… Just concept, when we’re teaching surgery, in terms of eye position, centrally, within the microscope — this is something that experienced surgeons do quite naturally. To try to keep the microscope centered on the pupil. But as you’re beginning to teach people, you may not think of this. So this is something that you always want to be cognizant of, as we’re instructing — as someone’s learning if the microscope — okay. Make sure you’re keeping the eye centrally positioned within the microscope. The intraocular spatial awareness, very important to avoid complications afterwards. If they have an understanding of anterior chamber depth. And so this tool is something you could use and implement in a wet lab setting, for SICS. And I realize there are probably people listening in who may be more interested in doing phaco wet labs. But doing manual small incision cataract surgery is a really good place to start for microsurgical training. It is a skill that, besides its low cost benefits and results, really can help in situations of problems with phacoemulsification. I actually use manual small incision cataract surgery when things get pretty hairy in my cataract surgeries now, in my practice. You know, pseudoexfoliation cases, where the lens is really tilting, and vitreous is coming into the anterior chamber. Manual small incision cataract surgery can bail me out, as opposed to having to call my retina colleagues, to rescue a nucleus that has taken a dive into the vitreous. So starting off training our learners with manual small incision cataract surgery, I really think, is a really nice place to start for them. And, you know, the long-term goal in mind, as we’re taking the time to teach our students in the wet lab, is that our learners are gonna be able to do safe cataract surgery independently, and have really good results. And so the investments in the short term to do things like wet lab will pay long-term dividends. And for us, running a blindness prevention program, the goal was on — okay, if I can do 20 cataract surgeries in the morning or whatever, by myself, I’m only one person. But in order to really make a big difference with blindness, the eradication program in the setting of Angola, the number of cataract surgeries really need to be multiplied. So it’s really tough for me to multiply myself physically, but by multiplying and training new doctors to do the cataract surgery, we really started to multiply the number of cataract surgeries that we were able to do in our project. So I really do want to thank you very much for the invitation to present, and thank you, Dr. Golnik, and I appreciate your time.

DR GOLNIK: I think there’s one question.

>> We do have one question, Dr. Clements, if you want to stop sharing your screen and then open up the QA box.

DR CLEMENTS: Yeah. So I’ll answer this question live and by text. Really I would put each of the globes inside of an examination glove. So just use an exam glove, open it up, put the globe inside of the glove, tie the glove off. No special fluid needed at that point. Just… At that point, put it in the deep freezer, and it keeps for at least several weeks. We would use them within several weeks after the procedure. But no special fluid media to store them. You would need to take them out and at least an hour or two prior to using them, they need to thaw well. It’s not really good for anybody to try to practice on a frozen globe. So it does require some preplanning, in order to take the globes out of the freezer ahead of time. Answering the Angola Center for Training — it is not open for other parts of Africa, unfortunately. Angola is a really difficult country to get into, in terms of a visa process. And their medical requirements are also similarly pretty difficult. So it is not something at this point that’s being used to train other doctors. I do have a good friend in South Africa, Dr. Colin Cooke, and a Dr. Will Dean, that are working on developing a training program for southern Africa, based out of Cape Town. It’s not ready for prime time yet. But they are working on that. I know there is a dearth of good places in specifically Sub-Saharan Africa, for good surgical training programs. But you can look that up. Dr. Colin Cooke. He’s at the University of Cape Town. And Dr. Will Dean. They’re working on it. So stay in touch, I suppose. And certainly Orbis has different training initiatives that Dr. Golnik can likely talk to, better than I can. All right. If there’s no other questions, I’ll turn it back to Dr. Golnik.